Striking a healthy balance

Deborah Punshon

Bolstering primary care, discharging hospital patients swiftly, and efficiently delegating work away from GPs are among the priorities to transform the health service in Scotland, according to the country’s health minister.

In an exclusive interview to answer questions posed by readers of this newspaper and its sister titles, Shona Robison said continuing to run the NHS in the same way “wouldn’t cut it” in the face of rocketing demand and an ever-ageing population.

Ms Robison makes her points. Picture: Greg Macvean

And the health minister was just as candid when answering a selection of your questions...

Q. What’s your biggest obstacle to providing the kind of Scottish health care system that would prevent and cure? (Tracey Guy, Rothesay)

A. Reducing health inequalities is one of the biggest challenges we face.

We need to shift our focus towards addressing the underlying causes of ending poverty, supporting families, and improving our physical and social environments.

Health Minister Shona Robison sets our her priorities for the future of the health service

We recently published a Fairer Scotland Action Plan which sets out 50 concrete actions that we will take over the course of this Parliament to tackle inequality, such as bringing forward a Child Poverty Bill setting ambitious 2030 income targets; establishing a new Best Start Grant aimed at low income families with children; tackling the poverty premium; and delivering at least 50,000 affordable homes over the current Parliamentary term. These actions are the right approach to take, coupled with decisive action to address alcohol consumption, reduce smoking rates, encourage active living, healthy eating, and promote positive mental health.

Q. Can you realistically transform the health service under crippling budget constraints? (Anon)

A. Demand continues to grow but the health budget continues to grow; it’s almost £13 billion now in its entirety.

It’s about making sure resources are getting to the frontline, and ensuring we invest in social care.

So we had £250 million last year going into social care and £170 million going into social care this next year.

It’s actually more important we transform services when there is a challenging financial environment. Doing the same when we have a changing population with more elderly people really doesn’t cut it.

We also have to maintain a quality of service, whether that’s community or acute, but we need to get that balance right so we can keep people out of hospital and keep those beds for people who absolutely need them.

We are asking boards to make efficiency savings but every pound that’s saved is re-invested into frontline services making sure they are running services as efficiently as possible.

Q. In light of recent delayed discharge figures, is the NHS being hampered by people who are not ill? (Mr C. McGrath, Borders)

A. We need to make sure people don’t end up in hospital when they don’t need to be there but more importantly, when they are ready for discharge they are discharged in a timely fashion. There is still a lot of work to be done, but there has been progress.

Over the last year, there’s been a nine per cent reduction in bed days lost to delay and there are now 11 out of 32 health and care partnerships which have delays in single figures.

The challenge now is for the other 20 or so to have that level of performance.

There are some areas that are struggling more than others. I’ve had those partnerships meet me face-to-face to talk about what it is they are doing and need to do to deliver some of the performances that other partnerships are delivering.

Progress is being made, not at the pace I want it to be, but it is going in the right direction.

Those other partnerships now need to up the pace to make sure they deliver the same level of performance.

If all partnerships were performing like the best 25 per cent, we’d half delays overnight.

Q. What is being done to tackle the GP crisis in Scotland and make it an attractive option? (Various readers)

A. The whole vision for primary care is going to make general practice more attractive, because what GPs tell me is that their day is difficult.

It’s like running to stand still, seeing everybody who comes through the door and they don’t have time to spend with patients they want to.

So the vision for primary care and the work we’re doing on the new contract with the British Medical Association is a complete re-design of how primary care is delivered.

Instead of the GP doing everything, we’ll have multi-disciplinary teams involving pharmacists, nurses and physiotherapists. The GP will be the clinical expert supporting that team but it may be that a patient won’t always be seen by a doctor but the best appropriate health care professional. We know that around 25 per cent of a GP’s work at the moment can be done by other health professionals, so it should be the case that we use those skills that other professionals bring, and enable the GP to spend more time with patients who absolutely need to see a doctor.

I’m confident that will encourage more doctors to choose general practice.

We also have our new graduate medical school opening in 2018 which is going to have a general practice as the centre of excellence so these will be graduates going into medicine from other disciplines, who are more likely to be more mature and who want to stay in Scotland.

But I don’t underestimate the challenges in the here and now. We expect boards to work early with practices in difficulty while we bring in this new way of working.

Q. When will governments cease to use the NHS as a political football and work cross party to increase spending per head to a fair, sustainable level in line with other nations? (Anne Stillman, Fife)

A. Scotland still spends more per head of population than the rest of these islands.

Treasury data shows it’s 7.2 per cent higher than in England. However, we need to make sure the resources are going to the right places and are delivering some of those changes that we need to make.

We can throw money after money at it but if it’s not actually delivering and sustaining services in the face of changing demographics then that’s not the best use of resources.

In terms of cross-party work, my door is always open to opposition members who want to come forward with constructive ideas that are affordable and deliverable.

I think where it gets tricky is when everything the government puts forward is opposed. That’s not realistic.

Health services do need to change; they are never frozen in time. Some of those decisions will be the right ones, some will be wrong.

When these decision come to me, I go through the evidence with a fine tooth comb and challenge those who are bringing forward ideas for change.

But I think to oppose every change, everywhere – sometimes that’s how it feels with the opposition – is not right or responsible. A balance has to be struck.

Q. How will you deal with the crisis affecting so many mental health patients? It’s beds that are needed rather than pushing desperate people out into the community. (Laura Templeton, East Renfrewshire)

A. Mental health is hugely important. The new mental health strategy is imminent and will set the vision for the next decade and beyond.

But we’ve backed that up with new resources like £150 million over the next five years to ensure mental health services are delivering the quality of service and access they need to.

Where someone is acutely ill, they of course should and must have access to an acute bed but that’s only for people who are acutely ill, not those who are not.

The idea that there’s not enough beds doesn’t hold water but it’s important that those beds are used for the right purpose.

The community mental health services, though, do need to be developed, bolstered and improved.

That’s again about keeping people out of hospital and providing rapid help when people need it, whatever their need is.

So that’s why we’re looking at what we can build into the new primary care model where we might have mental health workers as part of a multi-disciplinary team. But be absolutely assured mental health has equal priority to physical health and the changes that we need to see over the next decade will help transform the access people have to help when they need it.

Q. What reassurance can you offer families with babies with cleft lip and/or palate that exceptionally high level of surgical outcomes will be maintained now the service has been centralised in Glasgow? (Kate Watson, Edinburgh)

A. The most important thing here is that there’s a safe, sustainable cleft surgery service for all patients across Scotland.

I looked at this in great detail. I took a lot of time. I met patients and clinicians from Edinburgh and Glasgow and I think I listened to all the views.

I approved the change to a single surgery service because I believed that the clinicians working together more closely could support each other and create a more sustainable team.

I also attached important conditions to the decision. I described a transitional period of six months after which progress would be reviewed to make sure it was working as it should.

And, in terms of standards, Scotland should participate in the UK Cleft Audit to make sure that the information and data was of the highest quality.

We wanted a consistent approach towards outreach services across Scotland and, absolutely key, no deterioration in service, so the number of multi-disciplinary outreach clinics would not be diminished.

I’ve made it very clear that the local outreach clinics will not reduce in number and will be determined by patient need. I will be watching very carefully to make sure that the conditions I have attached are followed.

Q. My question is about organ donation. Will the Scottish Government be acting upon the results of the survey, or using it only as a guide? I fear greatly that the public will answer the survey with their hearts, and say they want this change, instead of looking at what facts are available. There is no evidence that opting out would increase donations, all it could do is reduce the size of the potential donor pool. (Dr Christine MacLeod, Edinburgh)

A. Organ and tissue donation is one of the greatest gifts a person can give and we are keen to explore all options to increase the number of donors. Our consultation closed on March 14 and we will now carefully analyse the responses it received.

The consultation had a presumption in favour of a soft opt out system, but any changes to the current system must ensure there is no harm to the public perception of organ donation, trust in the NHS or the safety of transplantation.

There is not one solution to increasing the number of organ donors and significant progress has already been made in increasing the numbers and delivering meaningful improvements through the recommendations in the Donation and Transplantation Plan for Scotland.

Thanks to the generosity of organ donors, the NHS in Scotland has achieved a huge amount in recent years. Since April 2016 there have been more than 120 deceased organ donors, more than in the whole of 2015-16. There has also been a year on year decrease in the number of people dying while waiting for an organ transplant.

Q. How many patients in Scotland have a diagnosis of Hidradenitis Suppurativa and how much does treating and managing HS cost the NHS annually? What steps are being taken to improve the treatment and care of HS patients? (Maggie Potter, and also the Scottish Alliance for Hidradenitis Suppurativa)

A. We absolutely recognise the impact that HS can have on the people who are living with the condition. Most people will be cared for locally with expert input as required, and we expect clinicians to follow guidance on treatment. I’m sorry that your reader hasn’t had a positive experience with their treatment. Across Scotland we’ve seen an increase in the number of specialist medical staff to help those with skin conditions. Over the past 10 years Consultant Clinical Dermatologists have increased by around a third, while the number of nurses specialising in dermatology has more than doubled. We’ve also committed to increase funding for primary care by £500m by 2021.

While information on the number of people with HS isn’t held centrally, the HS Trust estimates that it affects around one per cent of the population.

Q. Scotland is the only part of the UK where healthcare is unregulated. When is Shona Robison going to reinstate our independent healthcare regulator, as required by law, to protect both patients and all working in healthcare? (Mrs Helen Livermore, Linlithgow)

A. NHS is regulated, and the body we charge with that is Healthcare Improvement Scotland (HIS). They work very closely with the health and Safety Executive by using the respective resources and expertise effectively. There’s also the professional regulator like the General Medical Council and the Nursing and Midwifery Council and I think the important thing about HIS is that it doesn’t just inspect and scrutinise, it also works to improve services. When it inspects a service is also lists improvements and it doesn’t pull its punches. The idea that HIS reports are a soft landing is wrong, they are hard-hitting, and they report on what they see. They also work with the boards to make improvements. So it’s an inspection and improvement service. They publish around 100 inspections and review reports in a range of clinical areas and have done a huge amount to improve things like the level of care-associated infection, patients safety programme which has reduced hospital mortality rates by making things safer. I am very clear that the HIS is delivering that level of not just inspections and scrutiny, but also improvement as well. There are some other changes on the horizon, for example from April 2018, there’s going to be a new duty of candour where health boards will be required to, for example, produce into the public domain, all significant adverse events reports. So when something goes wrong, they will be required legally to report that. So there are things happening all the time around making things more transparent and improving safety and quality of service and HIS has a really important role to play.

Q. How you think Scotland’s NHS will be affected by the Comprehensive Economic and Trade Agreement (CETA), given that it has not been exempted from the deal? (Gillian Cummings, Isle of Mull)

A. We had concerns about the treaty which is why Keith Brown had written to the UK Government, basically saying that it’s essential that CETA doesn’t limit the Scottish Government’s ability to determine how and by whom the NHS and other public services are managed and provided in Scotland and it shouldn’t result in lower environmental, food and other standards, and that the Scottish Government and the Scottish Parliament must be able to regulate in the public interest without fear of being sued. That was a very clear outline of the concerns that people had around CETA, and Keith Brown asked for assurance from Liam Fox of theses important points and also in January, the Scottish Government wrote in similar terms to the Lord Price, the Minister of State for Trade Policy because Liam Fox hadn’t responded and indeed Lord Price has not responded. This is disappointing because we do want these assurances, and of course as the member state they will be negotiating around these issues as the constitution stands at the moment. It’s important they take seriously the concerns people have about trade deals like CETA. We understand the need for trade deals but we wanted those assurances, but so far we have not had the response we would have liked.

Q. Plans to transform the health service talk about preventing illness in the first place, making people more responsible for their own care, and creating a culture of healthy behaviours? Why then has the number of nurses in our schools diminished? Are school years not when children learn how to look after themselves and is it not a time when they are most at risk of developing bad habits? (Anon)

A. There has been a small decline in school nurses - two per cent. The school nurse role is very important and remains so, but it is changing to focus on children and families who are the most vulnerable. There’s been a review of the school nursing role and that was the outcome. So we need to make sure that boards and the local authority partners have the right number of school nurses in order to deliver that role. The workforce plan that will be published soon needs to make sure that in all of these areas that the right number of nurses coming through, and the right training opportunities for those who want to go into a school nursing role.

There’s a lot of work around prevention, whether it’s the expansion of health visitors to work with early years to make sure children get the best start or the work that’s going on around alcohol and smoking which show really really good results. Fewer than ever young people are taking up smoking, for example, and the impact of that in a few decades is going to be immense for the health service because we won’t see the same number of respiratory conditions or lung cancers cases. Young people are making different choices. That’s something to be celebrated. But there is more work to be done on public health and help people self manage their conditions and working with organisations like the Alliance to help people so they know what’s best to do, what not to do and keep their health the best. Informed patients are always able to look after their health better. The health board has an important role in creating informed patients, through community health services or primary care or secondary care and working with third sector organisations like the Alliance who have been expanding what they do.